Abstract Low back pain is the second most common reason for visiting a physician and the leading cause of pain in the U.S., with enormous costs driven primarily by 7-10% of patients who develop chronic pain and disability. The incidence of chronic low back pain (CLBP) is steadily rising and greater reliance on pharmacological and surgical intervention has not improved outcomes. Pain-related fear has emerged as one of the most important psychosocial risk factors for transition to and maintenance of CLBP. High fear individuals become trapped in a cycle of continued pain and disability through avoidance of common physical activities. The leading intervention to address pain-related fear and disability is graded exposure in-vivo, which involves gradual confrontation of avoided activities aimed to correct inaccurate expectations of pain and harm. However, the success of exposure intervention has been significantly hampered by issues of high resource cost, limited accessibility/dissemination, and low patient engagement. This treatment development plan brings together experts from medicine, psychology, and virtual reality (VR) gaming to integrate graded exposure into a gaming environment utilizing the innovative depth-sensing and motion-tracking features of existing gaming technology. This novel approach addresses limitations of current exposure intervention by reducing treatment costs, promoting access and dissemination, and improving treatment gains by (1) utilizing inexpensive widely available technology, (2) allowing distal tracking of patients across psychological and behavioral outcomes, (3) facilitating intervention in a variety of treatment settings, and (4) increasing patient engagement, adherence, and motivation through gamification. Following treatment development, we aim to perform a multicenter clinical trial to examine the efficacy of a home-based VR gaming intervention to decrease pain-related fear and disability among individuals at risk for CLBP (the ?Virtual Reality Graded Exposure? (VRGE) Trial). As part of Aim 1, the expert Steering Committee will plan an effective intervention paradigm, and design, develop and test the VR gaming interface. Aim 2 will establish the safety and feasibility of the intervention among high fear participants at risk for chronic pain, including a laboratory-based trial followed by a home-based trial. Additional outcomes of interest will include pain intensity, pain interference, physical function, psychosocial outcomes, and analgesic consumption. Quantitative and focus group findings from pilot testing will inform further refinement of the intervention. As part of Aim 3, the Steering Committee will write a manual of operations (MOOP) for the anticipated VRGE Trial and prepare an R01 submission for the VRGE Trial. The use of a VR gaming intervention represents an innovative approach to address pain-related fear and disability among individuals at risk for CLBP. The treatment can have a significant impact on public health by providing a low- cost intervention designed to promote access, dissemination, and patient engagement. Ultimately, this intervention is expected to reduce pain, disability, and maladaptive coping with pain such as excessive analgesic consumption.